Interim Statement on the Treatment of Gonorrhea In Canada

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After more than 2 decades of decline, the rate of gonorrhea in Canada began to rise in the late 1990s. From its lowest point in 1997, the rate has increased by almost 60% to 23.5 per 100 000 (7185 cases) in 2002.

Uncomplicated cases of gonorrhea can be treated with single-dose antimicrobial therapy, which helps to ensure adherence/compliance. However, emerging and prevalent resistance of N. gonorrhoeae strains continues to challenge the treatment, prevention and control of this infection. This highlights the importance of ongoing monitoring and reporting of antimicrobial resistance and the need for enhanced epidemiological data such as MSM or heterosexual contact.

Penicillin and tetracycline resistant strains of N. gonorrhoeae are well documented around the world, and therefore the use of these medications to treat gonorrhea is not recommended. More recently flouroquinolone (FQ) resistance has become an issue. First identified in 1992, FQ resistance is currently most prevalent in the Far East , but has been documented in many parts of the world, including the UK , the US and Canada.

Once resistance rates to an antibiotic reach 3-5% (depending on the jurisdiction) that treatment regimen can no longer be recommended. As such the use of FQs is not recommended for the treatment of gonorrhea in Asia, the Pacific Islands (including Hawaii), California, Israel, India, Australia, UK and most recently in MSM in the US (or in cases with contacts from these regions, or in cases that are epidemiologically linked to these areas).

Preliminary FQ resistance rates in Canada have been reported at 2.1% in 2002 and 1.99% for 2003 (please note that the 2003 data does not include Nova Scotia ). These rates are based on isolates with decreased susceptibility to at least one antibiotic sent from provincial laboratories to the National Microbiology Laboratory. However, data on FQ resistance from individual provinces and territories has indicated that FQ resistance is significant in some regions in Canada with some provinces reporting preliminary resistance rates as high as 12.5%. As a result the treatment recommendations for gonorrhea in Canada need to be revisited.

As you may already know, the current Canadian STD Guidelines (1998) are in the process of being updated, with a target release of summer 2005. The effort to revise the chapters of the 1998 version to produce an updated, evidence-based guidelines document began in March 2003. The revisions are currently being undertaken on a voluntary basis by experts across the country who write and review the chapters, and is coordinated by an Expert Working Group chaired by Dr. Tom Wong (Director, Community Acquired Infections Division, CIDPC, Public Health Agency of Canada). The revised version of the Canadian STD Guidelines will reflect the changes that have occurred in FQ resistance of N. gonorrhoeae since the 1998 edition.

However to ensure the effective and appropriate treatment of gonorrhea in Canada, an Interim statement on the Treatment of Gonorrhea in Canada has been produced and can be found below. This statement will be incorporated into the revised version of the Canadian STD Guidelines.

• Recommended treatment for Youth and Adults with Urethral, Endocervical, Rectal or Pharyngeal Infection (except pregnant and nursing mothers):
  • Cefixime 400 mg PO in a single dose or
  • Ceftriaxone 125 mg IM in a single dose or
  • *Ciprofloxacin 500 mg PO in a single dose (please see *CAUTION notes below) or
  • *Ofloxacin 400 mg PO in a single dose (please see *CAUTION notes below)
    
  
  
• *CAUTION: Quinolones (e.g. Ciprofloxacin and Ofloxacin) are not recommended for the treatment of gonorrhea if the case or contact are from, or are epidemiologically linked to:
  • Asia
  • Pacific Islands (incl. Hawaii )
  • India
  • Israel
  • Australia
  • UK
  • California
  • Washington State
  • Arizona ( Maricopa County )
  • Michigan (Ingham, Clinton , Eaton, Jackson , Livingston and Shiawassee Counties )
  • MSM with contact/epi linked to US
  • Certain areas within Canada are currently experiencing higher rates of FQ resistance – please check with your local public health officials to learn more about N. gonorrhoeae resistance and the use of quinolones in your area.
  • Other areas of high FQ resistant N. gonorrhoeae prevalence (greater than 3-5%)

  (This list will continue to be updated as more information becomes available. Please check the Public Health Agency of Canada Web site for the latest information.)

• Recommended treatment if use of quinolones not appropriate:
  • Cefixime 400 mg PO in a single dose or
  • Ceftriaxone 125 mg IM in a single dose
    
  
  
• If quinolones not recommended and cephalosporin allergy or immediate/anaphylactic penicillin allergy:
  • Azithromycin* 2g PO in a single dose or
  • Spectinomycin 2g IM in a single dose (available only through the Special Access Programme or SAP)

ONLY if the above recommended treatments are not tolerated or available, may quinolones (e.g. ciprofloxacin, ofloxacin) be considered. Treatment with quinolones MUST be followed by a test of cure and is ONLY acceptable for patients who are likely to present for follow-up testing. Ciprofloxacin 500 mg PO in a single dose or Ofloxacin 400 mg PO in a single dose

* A 2g dose of azithromycin is associated with a significant incidence of gastrointestinal adverse effects. Taking the tablet formulation with food may minimize such adverse effects. Antiemetics may be needed.

• Treatment of Pregnant or Nursing Mothers remains unchanged:
  • Preferred
    • Cefixime 400 mg PO in a single dose or
    • Ceftriaxone 125 mg IM in a single dose
  • Alternative
    • Spectinomycin 2g IM in a single dose (available only through the Special Access Programme or SAP)
• Treatment of Children under 9 years of age remains unchanged:
  • Preferred
    • Cefixime 8 mg/kg PO in single dose (max 400mg) or
    • Ceftriaxone 125 mg IM in a single dose
  • Alternative
    • Spectinomycin 40 mg/kg IM (max 2g) in a single dose

Notes:

Cefixime and ceftriaxone should not be given to persons with cephalosporin allergy or a history of immediate and/or anaphylactic reactions to penicillins.

The preferred diluent for ceftriaxone is 1% lidocaine without epinephrine (0.9 ml/250 mg, 0.45 ml/125 mg) to reduce discomfort.

Ciprofloxacin and Ofloxacin are contraindicated in pregnant and breastfeeding women

If spectinomycin is used, a test of cure is recommended. Spectinomycin should not be used to treat pharyngeal infections.

All treatment regimens should be followed by empiric therapy for chlamydial and non-gonococcal infections (with the exception of azithromycin which covers both).